International Journal of Gynecology and Obstetrics 131 (2015) S40–S42

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International Journal of Gynecology and Obstetrics

journal homepage: www.elsevier.com/locate/ijgo

REPRODUCTIVE HEALTH

Adolescent sexual and reproductive health: The global challenges

Jessica L. Morris ⁎, Hamid Rushwan
International Federation of Gynecology and Obstetrics, London, UK

a r t i c l e i n f o a b s t r a c t

Keywords: Adolescent sexual and reproductive health (ASRH) has been overlooked historically despite the high risks that
Abortion countries face for its neglect. Some of the challenges faced by adolescents across the world include early pregnan-
Adolescents cy and parenthood, difficulties accessing contraception and safe abortion, and high rates of HIV and sexually
Contraception transmitted infections. Various political, economic, and sociocultural factors restrict the delivery of information
HIV/AIDS and services; healthcare workers often act as a barrier to care by failing to provide young people with supportive,
Pregnancy
nonjudgmental, youth-appropriate services. FIGO has been working with partners and its member associations
Sexual and reproductive health
to break some of these barriers—enabling obstetricians and gynecologists to effect change in their countries
and promote the ASRH agenda on a global scale.
© 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. This
is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
Adolescent sexual and reproductive health (ASRH) comprises a
major component of the global burden of sexual ill health. Although
overlooked historically, international agencies are now focusing on im-
proving ASRH and providing programmatic funding. ASRH rights are
based in various legal instruments: in 2002, the UN General Assembly
Special Session on Children recognized the need to develop and imple-
ment health policies and programs for adolescents that promote their
physical and mental health [1]; in 2003, the Committee of the Conven-
tion on the Rights of the Child issued a General Comment recognizing
the special health and development needs and rights of adolescents
and young people [2]. Other supporting instruments are the Convention
on the Elimination of All Forms of Discrimination Against Women
(CEDAW) and the right to health—a concept included in various inter-
national agreements such as the Universal Declaration of Human Rights
and the international Millennium Development Goals, which include in-
dicators to reduce pregnancy rates among 15–19 year olds, increase HIV
knowledge, and reduce the spread of HIV among young people [3–5].
Various terms are used to categorize young people: “adolescents” re-
fers to 10–19 year olds (divided into early [10–14 years] and late
[15–19 years] adolescence); “youth” refers to 15–24 year olds; and
“young people” refers to 10–24 year olds. In the world today, approxi-
mately half of the population is under 25, with 1.8 billion people aged be-
tween 10 and 24 years—90% of whom live in low- and middle-income
countries (LMICs) and many experiencing poverty and unemployment
[6,7]. While sexual initiation and sexual activity vary widely by region,
country, and sex [8], in all regions young people are reaching puberty ear-
lier, often engaging in sexual activity at a younger age, and marrying later
[9–11]; consequently they are sexually mature for longer before marriage
than has historically been the case.
The risks of neglecting ASRH are great; a painful or damaging transition
to adulthood can result in a lifetime of ill effects. For girls, early pregnancy/
motherhood can be physically risky and can compromise educational
achievement and economic potential. Adolescents—girls in particular—face
increased risk of exposure to HIV and sexually transmitted infections
(STIs), sexual coercion, exploitation, and violence. All of these have huge
impacts on an individual’s physical and mental health, as well as long-
term implications for them, their families, and their communities.
An adolescent’s sexual and reproductive health is strongly linked to
their particular social, cultural, and economic environment. In addition to
regional variation, experiences are diversified by age, sex, marital status,
schooling, residence, migration, sexual orientation, and socioeconomic sta-
tus, among other characteristics. Access to health care and sources of edu-
cation, information, and support also varies widely. The variations demand
country-level analyses of patterns but despite these variations, key issues,
barriers, and challenges, as well as potential solutions, can be identified
across the board.
2. The global challenges
2.1. Pregnancy, contraception, and abortion

⁎ Corresponding author at: International Federation of Gynecology and Obstetrics
(FIGO), FIGO House, Suite 3, Waterloo Court, 10 Theed Street, London SE1 8ST, UK. Tel.:
+44 20 7928 1166; fax: +44 20 7928 7099.
E-mail address: Jessica@figo.org (J.L. Morris).
Sixteen million girls aged 15–19 give birth each year, which is ap-
proximately 11% of all births worldwide [12]; 95% of these births
occur in LMICs. Important regional differences exist; for example, births
to adolescents as a percentage of all births range from approximately 2%

http://dx.doi.org/10.1016/j.ijgo.2015.02.006
0020-7292/© 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
 J.L. Morris, H. Rushwan / International Journal of Gynecology and Obstetrics 131 (2015) S40–S42
in China, to 18% in Latin America and the Caribbean, to more than 50% in
Sub-Saharan Africa [13]. Pregnancy among very young mothers is a sig-
nificant problem; in LMICs, almost 10% of girls become mothers by age
16, with the highest rates in Sub-Saharan Africa and South Central and
Southeast Asia [13]. Pregnancies among unmarried adolescent mothers
are more likely to be unintended and end in induced abortion; coerced
sex (reported by 10% of girls who first had sex before age 15) contrib-
utes to unwanted adolescent pregnancies, among a plethora of other
negative consequences [13].
Adolescents face a higher risk of complications and death as a result of
pregnancy than older women. For example, in Latin America, the risk of
maternal death is four times higher in adolescents under 16 years old
than women in their twenties [12]. In terms of complications, anemia,
malaria, HIV and other STIs, postpartum hemorrhage, and mental
disorders, such as depression, are associated with adolescent pregnancy
[13,14]. Pregnancy and delivery for girls who have not completed their
body growth expose them to problems that are less common in adult
women; 9% − 86% of women with obstetric fistula develop the condition
as adolescents, with traumatic, often lifelong consequences [15]. Low
socioeconomic status, substance abuse, and likelihood of receiving
low and/or inadequate prenatal care are associated with pregnant
adolescents, and poor outcomes for the offspring of adolescent
mothers are well documented and include higher rates of preterm
birth, low birth weight and asphyxia, and perinatal and neonatal
mortality [10,12,16].
Globally, it is estimated that more than 220 million women in LMICs
have an unmet need for family planning [18]. Overall, little progress has
been made in increasing uptake of contraception. While increases in use
have been slightly higher with adolescents than older women, this
group are more affected by contraceptive failure and discontinuation
rates, and use of traditional methods of contraception are still notable
[11,17]. Adolescent girls who have ever had sex or are currently sexual-
ly active are more likely to be or have been married than boys in the
same categories [19]. Married adolescents often do not want a pregnan-
cy, but have low contraceptive rates; in fact, recent data have shown
that current use of contraceptives is often lower among sexually active,
married adolescents [11]. For example, in Bangladesh contraceptive use
among women aged 10–49 years rose from 49% − 61% from
1996–2011, while for married adolescents aged 15–19 years it rose
from 33% − 47% in the same time period [20]. Similarly, in Malawi, con-
traceptive use among married women aged 15–49 years increased from
13% − 46% from 1992–2010, whereas among married adolescents aged
15–19 years it rose from 7% − 29% [20]. Unmet need for both married
and unmarried adolescents is therefore still extremely high [8]. Re-
search suggests that current contraceptive use prevents approximately
272 000 maternal mortalities per year, and if current family planning
needs were met, another 104 000 lives would not be lost [21], many
of which would be adolescents’ lives saved.
One major outcome of unmet need for family planning is unwanted
pregnancy and, consequently, high levels of unsafe abortion. Complica-
tions from pregnancy and childbirth are the leading cause of death in
girls aged 15–19 years in LMICs where almost all of the estimated three
million unsafe abortions occur [16]. Worldwide, mostly as a result of un-
intended pregnancy, nearly 4.5 million adolescents undergo an abortion
each year, with approximately 40% performed under unsafe conditions.
Regional differences exist; for example, 15–19 year olds account for
25% of all unsafe abortions in Africa, but the proportion in Asia and in
Latin America and the Caribbean is much lower [22]. In Nigeria, adoles-
cents account for up to 74% of all induced abortions—approximately
60% of all gynecological hospital admissions. In Tanzania, approximately
half the number of adolescent patients seeking abortions were aged
17 years or younger [19]. Adolescents are more seriously affected by
complications than older women [12]. The physically devastating poten-
tial consequences of unsafe abortion include cervical tearing, perforated
uterus and bowel, hemorrhage, chronic pelvic infection and abscesses, in-
fertility, endotoxic shock, renal failure, and death. The long-term
S41
sequelae include ectopic pregnancy, chronic pelvic pain, and infertility
[23]. Potential discrimination and rejection by family or community
members, psychosocial stress, forced marriage, and violence often impact
these young women [19].
2.2. HIV/AIDS and STIs
Young people are currently the group most severely impacted by
HIV/AIDS. In 2009, young people aged between 15 and 24 years
accounted for 41% of all new HIV infections among adults over the age
of 15 and it is estimated that worldwide there are five million young
people (15–25 years) living with HIV. Most of these young people live
in Sub-Saharan Africa, most are women, and most do not know their
status. Globally, young women make up more than 60% of all young
people living with HIV, and in Sub-Saharan Africa that rate jumps to
72% [24] with prevalence among teenage girls in some countries five
times higher than among teenage boys [25]. Rates of STIs also show
the highest prevalence among 20–24 year olds, followed by 15–19
year olds, again often with adolescent girls bearing the higher burden
[26]. Biologically, the immature reproductive and immune systems of
adolescent girls translate to increased susceptibility to STIs and HIV
transmission [9,25]. In addition to biological vulnerability, cultural and
socioeconomic factors—particularly social inequality and exclusion, as
well as having older partners—increase their susceptibility.
Treating STIs is essential because they can facilitate the transmission of HIV
as well as causing lasting damage. Only a minority of adolescents have access
to any acceptable and affordable STI/HIV services. In most countries, compre-
hensive and accurate knowledge about HIV is low and HIV testing in this age
group is rare [27]. Outcomes for young people with HIV are poor; while a re-
cent analysis estimated a 32% decrease in AIDS-related deaths among non-
adolescents (aged 0–9 years and aged 20 and older) between 2005 and
2012, among adolescents (aged 10–19 years) there was a 50% increase in
AIDS-related deaths, especially among boys [28].
3. Barriers and challenges
A series of multifaceted barriers currently prohibits good sexual and
reproductive health for adolescents. At the political level, ASRH is low
priority and there are often restrictive laws and policies in place. Various
societal, cultural, and religious factors create an inhibitive environment
for discussion of ASRH as many societies hold a deeply embedded sense
of disapproval of adolescent sexual activity; this is often demonstrated
through the stigmatization of sexual health concerns, in particular
STIs/HIV. Judgmental attitudes about sexual activity abound, especially
for those out of marriage and sexually active girls and women. In
some regions, accepted practices of early marriage and childbearing,
age differences between partners, and societal pressure prohibiting
use of contraceptive methods may also exist. Poor ASRH can be further
confounded by conflict, migration, urbanization, and lack of schooling.
With regard to service-related barriers, poor health systems for sex-
ual health, family planning, and maternal health are common, with un-
married adolescents ignored in some cases, married adolescents in
others, and an overall deficiency of youth-friendly services. Lack of inte-
gration is seen where services that might address counselling and fam-
ily planning fail to include HIV/STI care, etc. Services may also be
hampered by corruption and lack/erratic availability of supplies and
equipment. Economic and physical accessibility restrict adolescents’ ac-
cess to services where they do exist. On a personal level, young people’s
care-seeking behavior may be restricted because of fear (of people find-
ing out and other confidentiality issues that may result in violence), em-
barrassment, lack of knowledge, misinformation and myths, stigma, and
shame [11]. A range of people have an influence on adolescents’ access
to information and services, including peers, parents, family members,
teachers, and healthcare workers. Some argue that the single most im-
portant barrier to care is provider attitude [29]. Many healthcare
workers deter adolescents from using services because of their lack of
S42 J.L. Morris, H. Rushwan / International Journal of Gynecology and Obstetrics 131 (2015) S40–S42
confidentiality, judgmental attitudes, disrespect, or not taking their
patients' needs seriously.
4. Opportunities and potential solutions
Opportunities for improving ASRH come from myriad directions.
With regard to services, we must ensure access to quality youth-
friendly, integrated services, provided by healthcare workers who
have been trained to work with adolescents. Sex education programs
should be scaled up and offer accurate, comprehensive information
while building skills for negotiating sexual behaviors [9]. Healthcare
workers should be equipped to provide accurate, balanced sex educa-
tion, including information about contraception and condoms so that
young people have the means to protect themselves, provided within
a context of healthy sexuality, without stigma or judgment.
Healthcare workers are also well placed to influence policy and en-
sure service provision for those who need it. For example, healthcare
workers can work to ensure young pregnant women receive early and
tailored prenatal services to address their high risk and specific problems
of anemia, malaria, HIV, and other STIs, as well as giving them special at-
tention during obstetric care, given that they are most at risk of compli-
cations and death. Many improvements require political and legal
maneuvering and healthcare workers can be advocates for legal abor-
tion, adequate postabortion care services for young people where abor-
tion is restricted or adolescents have difficulty in accessing legal
abortions, contraception provision for all who have unmet need, as
well as other ASRH initiatives that can have a direct and strong impact
on adolescent health.
5. What is FIGO doing?
To determine how best to lever its strengths to effectively contribute
to improving adolescent health, FIGO commissioned a review of its
ASRH activities and research including a literature review on adolescents’
attitudes toward sexual and reproductive health and their perceptions of
health professionals, ASRH programs and their level of effectiveness, and
tools and guidelines available on ASRH. Utilizing its member associations,
FIGO conducted a KAP survey (knowledge, attitudes, and perceptions)
with obstetricians and gynecologists. The findings highlighted the impor-
tant role FIGO could play by engaging more deeply and strategically in
ASRH initiatives through strengthening the credible voice of obstetricians
and gynecologists in support of increasing young people’s access to high-
quality contraceptive and safe abortion services. To do this, FIGO has been
conducting regional workshops bringing together obstetricians and youth
in Africa, Asia, Latin America, and Europe. These workshops provide space
for obstetricians and gynecologists to meet with young people to discuss
important issues, generate practical and innovative strategies for improv-
ing ASRH, and strengthen the capacity of obstetricians and gynecologists
to advocate and provide better sexual and reproductive care for young
people. FIGO hopes to continue these activities as well as build on its
ASRH portfolio in the coming years.
6. Conclusion
Innumerable health and social challenges face young people in all
countries; it is time to improve our understanding of this age group
and to focus our energies on alleviating these problems. Political efforts
need to be directed to providing youth-appropriate services, and the
health establishment must follow a comprehensive, evidence-based ap-
proach that raises the capacity of health workers and implements bold
initiatives for, and with, adolescents. Importantly, obstetricians and
gynecologists—through their national associations and through FIGO
at the international level—have an important role to play in the ad-
vancement of ASRH services so that healthcare workers move from
being part of the problem to part of the solution. FIGO is committed to
promoting ASRH. Addressing the global challenges of adolescent health
is critical to the future of a country’s health and must be led by those at
the vanguard—the healthcare workers.
Conflict of interest
The authors have no conflicts of interest to declare.
References
[1] United Nations. Resolution adopted by the General Assembly [on the report of the
Ad Hoc Committee of the Whole (A/S-27/19/Rev.1 and Corr.1 and 2)] S-27/2. A
world fit for children 2002. 11 October 2002 Twenty-seventh special session.
http://www.unicef.org/specialsession/docs_new/documents/A-RES-S27-2E.pdf.
[2] United Nations. Convention on the Rights of the Child. General Comment No. 4
(2003). Adolescent health and development in the context of the Convention on
the Rights of the Child. CRC/GC/2003/4 http://daccess-dds-ny.un.org/doc/UNDOC/
GEN/G03/427/24/PDF/G0342724.pdf?OpenElement.
[3] United Nations. Convention on the Elimination of All Forms of Discrimination
against Women (CEDAW). http://www.un.org/womenwatch/daw/cedaw/.
Accessed October 24, 2014.
[4] World Health Organization. The Right to Health. Fact Sheet No. 31. http://www.who.
int/hhr/activities/Right_to_Health_factsheet31.pdf?ua=1.
[5] United Nations. The Millennium Development Goals (MDGs). http://www.un.org/
millenniumgoals/. Accessed October 24, 2014.
[6] UNFPA. Adolescent and youth demographics: A brief overview. http://www.unfpa.
org/resources/adolescent-and-youth-demographicsa-brief-overview.
[7] The World Bank Group. The Challenge: Reducing Poverty. http://www.worldbank.
org/progress/reducing_poverty.html. Accessed October 24, 2014.
[8] Chandra-Mouli V, McCarraher DR, Phillips SJ, Williamson NE, Hainsworth G.
Contraception for adolescents in low and middle income countries: needs, barriers,
and access. Reprod Health 2014;11(1):1.
[9] Bearinger LH, Sieving RE, Ferguson J, Sharma V. Global perspectives on the sexual
and reproductive health of adolescents: patterns, prevention, and potential. Lancet
2007;369(9568):1220–31.
[10] Chen XK, Wen SW, Fleming N, Demissie K, Rhoads GG, Walker M. Teenage pregnan-
cy and adverse birth outcomes: a large population based retrospective cohort study.
Int J Epidemiol 2007;36(2):368–73.
[11] Blanc AK, Tsui AO, Croft TN, Trevitt JL. Patterns and trends in adolescents' contracep-
tive use and discontinuation in developing countries and comparisons with adult
women. Int Perspect Sex Reprod Health 2009;35(2):63–71.
[12] World Health Organization. Adolescent pregnancy. Fact sheet No. 364.September 2014.
http://www.who.int/mediacentre/factsheets/fs364/en/. Accessed October 24, 2014.
[13] World Health Organization. Maternal, newborn, child and adolescent health. Adoles-
cent pregnancy. http://www.who.int/maternal_child_adolescent/topics/maternal/
adolescent_pregnancy/en/. Accessed October 24, 2014.
[14] Hodgkinson SC, Colantuoni E, Roberts D, Berg-Cross L, Belcher HM. Depressive
symptoms and birth outcomes among pregnant teenagers. J Pediatr Adolesc
Gynecol 2010;23(1):16–22.
[15] Tebeu PM, Fomulu JN, Khaddaj S, de Bernis L, Delvaux T, Rochat CH. Risk factors for
obstetric fistula: a clinical review. Int Urogynecol J 2012;23(4):387–94.
[16] Lopez LM, Hiller JE, Grimes DA. Education for contraceptive use by women after
childbirth. Cochrane Database Syst Rev 2012;8:CD001863.
[17] IPPF. Facts on the sexual and reproductive health of adolescent women in the devel-
oping world. New York: Guttmacher Institute; 2010http://www.guttmacher.org/
pubs/FB-Adolescents-SRH.pdf.
[18] Singh S, Darroch JE. Adding it up: costs and benefits of contraceptive service. Esti-
mates for 2012. New York: Guttmacher Institute and UNFPA; 2012http://www.
guttmacher.org/pubs/AIU-2012-estimates.pdf.
[19] World Health Organization. Adolescent pregnancy: unmet needs and undone deeds.
A review of the literature and programmes. Geneva: WHO; 2007.
[20] United Nations. Adolescent fertility since the International Conference on Population
and Development (ICPD) in Cairo. New York: United Nations; 2013.
[21] Ahmed S, Li Q, Liu L, Tsui AO. Maternal deaths averted by contraceptive use: an anal-
ysis of 172 countries. Lancet 2012;380(9837):111–25.
[22] Grimes DA, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, et al. Unsafe
abortion: the preventable pandemic. Lancet 2006;368(9550):1908–19.
[23] Ibrahim IA, Onwudiegwu U. Sociodemographic determinants of complicated unsafe
abortions in a semi-urban Nigerian town: a four-year review. West Indian Med J
2012;61(2):163–7.
[24] UNICEF. Opportunity in crisis: Preventing HIV from early adolescence to early adult-
hood. New York: UNICEF; 2011.
[25] UNICEF. Goal: Promote gender equality and empower women. http://www.unicef.
org/mdg/index_genderequality.htm. Accessed November 1, 2014.
[26] Dehne K, Riedner G. Sexually Transmitted Infections among adolescents. The need
for adequate health services. Geneva: WHO; 2005.
[27] Idele P, Gillespie A, Porth T, Suzuki C, Mahy M, Kasedde S, et al. Epidemiology of HIV
and AIDS among adolescents: current status, inequities, and data gaps. J Acquir Im-
mune Defic Syndr 2014;66(Suppl. 2):S144–53.
[28] Leach-Lemens C. Adolescent deaths from AIDS rising, especially among boys. London:
NAM Publications; 2014http://www.aidsmap.com/Adolescent-deaths-from-AIDS-
rising-especially-among-boys/page/2893246/. Accessed November 7, 2014.
[29] International Federation of Gynecology and Obstetrics. Adolescent sexual and repro-
ductive health (ASRH). London: FIGO; 2011http://www.figo.org/figo-project-
publications.